{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T19:58:41Z","timestamp":1787774321445,"version":"build-2784847793"},"reference-count":52,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,7,23]],"date-time":"2025-07-23T00:00:00Z","timestamp":1753228800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Health Serv."],"abstract":"<jats:sec><jats:title>Background<\/jats:title><jats:p>Labor companionship, the presence of a woman's person of choice during childbirth, has benefits to both woman and baby and is recommended by the World Health Organization since 2012. However, implementation remains sub-optimal, especially in low-and-middle-income countries (LMICs). This study aimed to understand the maturity of labor companionship implementation in eight low-and-middle income countries with focus on the policy and facility environment.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>This was a multi-country study nested in two hospital-based implementation research studies: Action Leveraging Evidence to Reduce perinatal mortality and morbidity in Sub-Saharan Africa (ALERT) study and the QUALIty DECision-making by women and providers for appropriate use of caesarean section (QUALI-DEC) study. We included 48 hospitals from eight countries: Argentina, Burkina Faso, Thailand and Viet Nam (QUALI-DEC) and four from each of Benin, Malawi, Tanzania and Uganda (ALERT). We used data from (i) a document review, including national policy documents and (ii) health facility readiness assessment, including physical layouts of maternity wards, all collected between December 2019 and April 2021. Our analysis included two steps, (1) a structured data abstraction with coding to pre-defined categories to analyse the national polices and available resources on a facility level which informed the (2) categorization of implementation maturity in three implementation phases modelled by the framework by Bergh et al. and the logic model developed by Bohren et al.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Three of the eight countries lacked any national-level companionship policies, four had some mentioning and only one had detailed guidance on roles of labor companions and implementation guidelines. The physical outlines of maternity wards varied greatly, and lack of space was one of the main implementation barriers to all countries except Argentina. We classified Benin, Thailand and Viet Nam in the pre-implementation phase because of missing guidelines and limited implementation; Burkina Faso, Malawi, Uganda and Tanzania in the early implementation phase; and Argentina in the institutionalization phase where policies and facility resources were conducive.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>Successful implementation was supported by concrete and contextualized implementation guidance. To move to high implementation levels, supporting policies, guidelines and structural changes in the maternity wards are needed.<\/jats:p><\/jats:sec>","DOI":"10.3389\/frhs.2025.1550473","type":"journal-article","created":{"date-parts":[[2025,7,23]],"date-time":"2025-07-23T05:36:06Z","timestamp":1753248966000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":3,"title":["Towards a universal implementation of labor companionship: a synthesis of the policy and facility environment of eight low-and-middle income countries"],"prefix":"10.3389","volume":"5","author":[{"given":"Soha","family":"El-Halabi","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea Barnabas","family":"Pembe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexandre","family":"Dumont","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ana Pilar","family":"Betr\u00e1n","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charles","family":"Kabor\u00e9","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Effie","family":"Chipeta","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Guillermo","family":"Carroli","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Helle M\u00f6lsted","family":"Alvesson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hussein","family":"Kidanto","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jean-Paul","family":"Dossou","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kristi Sidney","family":"Annerstedt","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lenka","family":"Be\u0148ov\u00e1","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mechthild M.","family":"Gross","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter","family":"Waiswa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pisake","family":"Lumbiganon","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Quoc Nhu Hung","family":"Mac","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Meghan A.","family":"Bohren","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claudia","family":"Hanson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2025,7,23]]},"reference":[{"key":"B1","first-page":"210","volume-title":"WHO Recommendations on Intrapartum Care for a Positive Childbirth Experience","year":"2018"},{"key":"B2","doi-asserted-by":"publisher","DOI":"10.1002\/14651858.CD003766.pub6","article-title":"Continuous support for women during childbirth","author":"Bohren","year":"2017","journal-title":"Cochrane Database Syst Rev"},{"key":"B3","first-page":"84","volume-title":"Standards for Improving Quality of Maternal and Newborn Care in Health Facilities","year":"2016"},{"key":"B4","volume-title":"WHO Recommendations for Augmentation of Labour","year":"2014"},{"key":"B5","volume-title":"WHO Recommendations on Health Promotion Interventions for Maternal and Newborn Health 2015","year":"2015"},{"key":"B6","first-page":"62","volume-title":"Clinical Management of COVID-19: Interim Guidance, 27 May 2020","year":"2020"},{"key":"B7","doi-asserted-by":"publisher","first-page":"1129","DOI":"10.1016\/S0140-6736(14)60789-3","article-title":"Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care","volume":"384","author":"Renfrew","year":"2014","journal-title":"Lancet"},{"key":"B8","doi-asserted-by":"publisher","first-page":"e0001476","DOI":"10.1371\/journal.pgph.0001476","article-title":"From global recommendations to (in)action: a scoping review of the coverage of companion of choice for women during labour and birth","volume":"3","author":"Bohren","year":"2023","journal-title":"PLOS Glob Public Health"},{"key":"B9","doi-asserted-by":"publisher","first-page":"e19","DOI":"10.26633\/RPSP.2020.19","article-title":"Status of national policy on companion of choice at birth in Latin America and the Caribbean: gaps and challenges","volume":"44","author":"De Mucio","year":"2020","journal-title":"Rev Panam Salud Publica Pan Am J Public Health"},{"key":"B10","doi-asserted-by":"publisher","first-page":"e054946","DOI":"10.1136\/bmjopen-2021-054946","article-title":"Factors influencing the implementation of labour companionship: formative qualitative research in Thailand","volume":"12","author":"Rungreangkulkij","year":"2022","journal-title":"BMJ Open"},{"key":"B11","doi-asserted-by":"publisher","first-page":"46","DOI":"10.1186\/s12978-023-01597-w","article-title":"Women\u2019s and health providers\u2019 perceptions of companionship during labor and childbirth: a formative study for the implementation of WHO companionship model in Burkina Faso","volume":"20","author":"Yaya Bocoum","year":"2023","journal-title":"Reprod Health"},{"key":"B12","doi-asserted-by":"publisher","DOI":"10.1002\/14651858.CD012449.pub2","article-title":"Perceptions and experiences of labour companionship: a qualitative evidence synthesis","author":"Bohren","year":"2019","journal-title":"Cochrane Database Syst Rev"},{"key":"B13","doi-asserted-by":"publisher","first-page":"378","DOI":"10.1016\/j.wombi.2021.09.003","article-title":"The impact of COVID-19 on the provision of respectful maternity care: findings from a global survey of health workers","volume":"35","author":"Asefa","year":"2022","journal-title":"Women Birth"},{"key":"B14","doi-asserted-by":"publisher","first-page":"e002967","DOI":"10.1136\/bmjgh-2020-002967","article-title":"Voices from the frontline: findings from a thematic analysis of a rapid online global survey of maternal and newborn health professionals facing the COVID-19 pandemic","volume":"5","author":"Semaan","year":"2020","journal-title":"BMJ Glob Health"},{"key":"B15","doi-asserted-by":"publisher","first-page":"1192473","DOI":"10.3389\/fgwh.2023.1192473","article-title":"Provision and utilization of maternal health services during the COVID-19 pandemic in 16 hospitals in sub-Saharan Africa","volume":"4","author":"Semaan","year":"2023","journal-title":"Front Glob Womens Health"},{"key":"B16","doi-asserted-by":"publisher","first-page":"53","DOI":"10.1186\/s13012-015-0242-0","article-title":"Making sense of implementation theories, models and frameworks","volume":"10","author":"Nilsen","year":"2015","journal-title":"Implement Sci"},{"key":"B17","doi-asserted-by":"publisher","first-page":"1102","DOI":"10.1111\/j.1651-2227.2005.tb02052.x","article-title":"Measuring implementation progress in kangaroo mother care","volume":"94","author":"Bergh","year":"2005","journal-title":"Acta Paediatr"},{"key":"B18","doi-asserted-by":"publisher","first-page":"e0243722","DOI":"10.1371\/journal.pone.0243722","article-title":"\u201cIt might be a statistic to me, but every death matters.\u201d: an assessment of facility-level maternal and perinatal death surveillance and response systems in four sub-Saharan African countries","volume":"15","author":"Kinney","year":"2020","journal-title":"PLoS One"},{"key":"B19","doi-asserted-by":"publisher","first-page":"304","DOI":"10.1186\/s12884-021-03746-0","article-title":"Birth companionship in a government health system: a pilot study in Kigoma, Tanzania","volume":"21","author":"Chaote","year":"2021","journal-title":"BMC Pregnancy Childbirth"},{"key":"B20","doi-asserted-by":"publisher","first-page":"937","DOI":"10.1111\/j.1471-0528.2010.02574.x","article-title":"Acceptability and experience of supportive companionship during childbirth in Malawi","volume":"117","author":"Banda","year":"2010","journal-title":"BJOG Int J Obstet Gynaecol"},{"key":"B21","doi-asserted-by":"publisher","first-page":"150","DOI":"10.1186\/s12884-018-1806-1","article-title":"Companionship during facility-based childbirth: results from a mixed-methods study with recently delivered women and providers in Kenya","volume":"18","author":"Afulani","year":"2018","journal-title":"BMC Pregnancy Childbirth"},{"key":"B22","doi-asserted-by":"publisher","first-page":"223","DOI":"10.1016\/j.ijgo.2014.12.005","article-title":"Perceptions about labor companionship at public teaching hospitals in three Arab countries","volume":"129","author":"Kabakian-Khasholian","year":"2015","journal-title":"Int J Gynecol Obstet"},{"key":"B23","doi-asserted-by":"publisher","first-page":"1324","DOI":"10.1186\/s12913-021-07155-z","article-title":"Action leveraging evidence to reduce perinatal mortality and morbidity (ALERT): study protocol for a stepped-wedge cluster-randomised trial in Benin, Malawi, Tanzania and Uganda","volume":"21","author":"Akuze","year":"2021","journal-title":"BMC Health Serv Res"},{"key":"B24","doi-asserted-by":"publisher","first-page":"72","DOI":"10.1186\/s13012-020-01029-4","article-title":"Implementation and evaluation of nonclinical interventions for appropriate use of cesarean section in low- and middle-income countries: protocol for a multisite hybrid effectiveness-implementation type III trial","volume":"15","author":"Dumont","year":"2020","journal-title":"Implement Sci"},{"key":"B25","doi-asserted-by":"publisher","first-page":"170","DOI":"10.1186\/s12978-019-0827-1","article-title":"Optimising the use of caesarean section: a generic formative research protocol for implementation preparation","volume":"16","author":"Bohren","year":"2019","journal-title":"Reprod Health"},{"key":"B26","article-title":"National Sexual and Reproductive Health and Rights Strategy 2021\u20132025","author":"Malawi","year":""},{"key":"B27","article-title":"Guidelines for Maternal and Newborn Health Services including family planning during the covid-19 pandemic","year":""},{"key":"B28","article-title":"Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC). National Guideline for Gender and Respectful Care Mainstreaming and Integration across RMNCAH services in Tanzania","year":""},{"key":"B29","article-title":"Essential Maternal and Newborn Clinical Care Guidelines for Uganda 2021","year":""},{"key":"B30","article-title":"Guia para la atencion del parto normal en maternidades centradas en la familia","year":""},{"key":"B31","article-title":"Ley N\u00b0 25.929- Parto Humanizado","year":""},{"key":"B32","article-title":"Participants Manual in Integrated Maternal and Neonatal Care","year":""},{"key":"B33","article-title":"National Standards for Improving the Quality of Maternal and Newborn care","year":""},{"key":"B34","first-page":"125","volume-title":"Protocole de Sant\u00e9 de la Reproduction: Sant\u00e9 de la Femme et du Nouveau-n\u00e9 de Moins de Sept (7) Jours","year":"2019"},{"key":"B35","doi-asserted-by":"publisher","first-page":"1068","DOI":"10.4102\/hsag.v23i0.1068","article-title":"Challenges in implementing continuous support during childbirth in selected public hospitals in the North West Province of South Africa","volume":"23","author":"Spencer","year":"2018","journal-title":"Health SA"},{"key":"B36","doi-asserted-by":"publisher","first-page":"392","DOI":"10.1186\/s12884-017-1578-z","article-title":"Is the policy of allowing a female labor companion feasible in developing countries? Results from a cross sectional study among Sri Lankan practitioners","volume":"17","author":"Senanayake","year":"2017","journal-title":"BMC Pregnancy Childbirth"},{"key":"B37","doi-asserted-by":"publisher","first-page":"1208","DOI":"10.1111\/1471-0528.15270","article-title":"Obstetric violence: a Latin American legal response to mistreatment during childbirth","volume":"125","author":"Williams","year":"2018","journal-title":"BJOG Int J Obstet Gynaecol"},{"key":"B38","doi-asserted-by":"publisher","first-page":"e0000102","DOI":"10.1371\/journal.pgph.0000102","article-title":"Partnership-defined quality approach to companionship during labour and birth in east new Britain, Papua New Guinea: a mixed-methods study","volume":"2","author":"Wilson","year":"2022","journal-title":"PLOS Glob Public Health"},{"key":"B39","doi-asserted-by":"publisher","first-page":"80","DOI":"10.1111\/birt.12471","article-title":"Coverage, associated factors, and impact of companionship during labor: a large-scale observational study in six hospitals in Nepal","volume":"47","author":"Ashish","year":"2020","journal-title":"Birth"},{"key":"B40","doi-asserted-by":"publisher","first-page":"102904","DOI":"10.1016\/j.midw.2020.102904","article-title":"Providing respectful maternity care in northern Ghana: a mixed-methods study with maternity care providers","volume":"94","author":"Moyer","year":"2021","journal-title":"Midwifery"},{"key":"B41","doi-asserted-by":"publisher","first-page":"e96","DOI":"10.1016\/S2214-109X(18)30403-0","article-title":"Person-centred maternity care in low-income and middle-income countries: analysis of data from Kenya, Ghana, and India","volume":"7","author":"Afulani","year":"2019","journal-title":"Lancet Glob Health"},{"key":"B42","doi-asserted-by":"publisher","first-page":"4","DOI":"10.1186\/s12978-017-0449-4","article-title":"Service providers\u2019 experiences of disrespectful and abusive behavior towards women during facility based childbirth in Addis Ababa, Ethiopia","volume":"15","author":"Asefa","year":"2018","journal-title":"Reprod Health"},{"key":"B43","doi-asserted-by":"publisher","first-page":"137","DOI":"10.1186\/s12978-018-0583-7","article-title":"Barriers and facilitators to humanizing birth care in Tanzania: findings from semi-structured interviews with midwives and obstetricians","volume":"15","author":"Mselle","year":"2018","journal-title":"Reprod Health"},{"key":"B44","doi-asserted-by":"publisher","first-page":"265","DOI":"10.1186\/s12884-017-1447-9","article-title":"Companion of choice at birth: factors affecting implementation","volume":"17","author":"Kabakian-Khasholian","year":"2017","journal-title":"BMC Pregnancy Childbirth"},{"key":"B45","doi-asserted-by":"publisher","first-page":"35","DOI":"10.1111\/apa.14540","article-title":"Implementation of a labour companionship model in three public hospitals in arab middle-income countries","volume":"107","author":"Kabakian-Khasholian","year":"2018","journal-title":"Acta Paediatr"},{"key":"B46","doi-asserted-by":"crossref","first-page":"1122","DOI":"10.1186\/s12913-023-10051-3","article-title":"Implementing a new birthing room design: a qualitative study with a care provider perspective","volume":"23","author":"Goldkuhl","year":"2023","journal-title":"BMC Health Serv Res"},{"key":"B47","first-page":"193","article-title":"Women\u2019s experiences of physical features in a specially designed birthing room: a mixed-methods study in Sweden","volume":"15","author":"Skogstrom","year":"2022","journal-title":"HERD-Health Environ Res Des J"},{"key":"B48","doi-asserted-by":"crossref","first-page":"102180","DOI":"10.1016\/j.eclinm.2023.102180","article-title":"Towards a better tomorrow: addressing intersectional gender power relations to eradicate inequities in maternal health","volume":"67","author":"Bohren","year":"2024","journal-title":"EClinicalMedicine"},{"key":"B49","article-title":"New World Bank country classifications by income level: 2022\u20132023","year":""},{"key":"B50","volume-title":"Births by Caesarean Section (%) (Maternal and Reproductive Health)","year":"2018"},{"key":"B51","first-page":"108","volume-title":"Trends in Maternal Mortality 2000 to 2020: Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA\/Population Division","year":"2023"},{"key":"B52","article-title":"The Global Health Observatory. (2020). Hospital beds (per 10 000 population)","year":""}],"container-title":["Frontiers in Health Services"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/frhs.2025.1550473\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,7,23]],"date-time":"2025-07-23T05:36:08Z","timestamp":1753248968000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/frhs.2025.1550473\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,7,23]]},"references-count":52,"alternative-id":["10.3389\/frhs.2025.1550473"],"URL":"https:\/\/doi.org\/10.3389\/frhs.2025.1550473","relation":{},"ISSN":["2813-0146"],"issn-type":[{"value":"2813-0146","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,7,23]]},"article-number":"1550473"}}